Utilization management (UM), care management, control of spiraling costs, and care coordination – are all the words we regularly hear these days with the advent of accountable care and increased enrollment in managed care plans across the country. But how do we manage patient care and optimize costs without withholding care?
That is the challenge.
In my mind, it cannot be a battle of wills between the primary providers and specialists or providers and patients, nor a question of denying what the patients need for their well-being.
We need a structured approach that eliminates room for error and human vulnerability to increase profit margins. The system must become financial-proof. I do not mean that we should not reduce wastage or do what is needed to reduce costs, but that the primary concern cannot be financial. Our primary concern must remain enhanced quality and reduced mortality and morbidity.
How do we structure a program that prevents us from succumbing to greed and ensures that we stay true to our higher selves?
These are some of the elements we need to introduce to a comprehensive care management program, in my opinion:
A methodical, consistent paradigm that touches the patients at multiple points and in an organized manner, reducing chance and catastrophic cases. This structured approach should ensure coordinated care and continuity of care, patient and family engagement, and education utilizing a multi-layered approach to interventions so patients do not fall through the cracks.
Seeing the patient as a social, emotional, mental, and spiritual being and not just a physical entity or a number is critical. Studies have shown that medical interventions can reduce costs by only 10%. Social, psychological, and behavioral interventions can have a significant impact, accounting for nearly 30% of the overall effect. A good UM program would have an astute team of psychologists, counselors, social workers, and behavioral therapists. It would also utilize community resources to ensure patient safety and active lives and include a focus on proper nutrition, hygiene, and injury prevention.
Continuity of Care
A program of seeing walk-in patients in the primary care providers, preferably on the same day with proper triage, would ensure patient satisfaction and reduce emergency room (ER) visits. Seeing one’s usual provider is always preferable to seeing a new provider in the ER. We must also ensure we see patients within seven days of hospital discharge. As Coleman has pointed out, this will reduce readmissions, morbidity, and drug-related complications. A strong hospitalist and SNFist program and Urgent Care Centers that provide weekend-care and after-hour care augmented by a team of case managers would ensure that communication and patient care do not break down.
The best way to optimize costs is to have a great relationship and communication with patients. Trust and credibility are the key. Patients must know that the provider only cares about what is best for them. Once we establish such a relationship, educating patients about proper habits, avoiding noxious activities, and disease management become easy. We can discuss end-of-life care without elements of antagonism or fear of ‘death squads’. We will also be able to focus on palliative care and dignity of life, along with patients’ rights. A patient who trusts his physician would be able to manage his conditions such as Diabetes Mellitus (DM), Congestive Heart Failure (CHF), or Coronary Artery Disease well – and might be willing to exercise and change habits that are good for them. We must educate patients not to use the ER as the primary source of care.
Claims Review Process
A provider that sees their expenses regularly is in better touch with patient care as specialist interventions can be reviewed and improved. Part D utilization, especially brand drugs, can be impacted.
The coordination of care among primary care providers and specialists and other associated medical staff, such as dieticians, diabetic educators, therapists, and others, is one of the most critical elements that affect a Patient-Centered Medical Home (PCMH). Facilitating the sharing of reports and data among these stakeholders and with patients would assist the patients who have begun to use the doctor’s office as their medical home.
Optimization of Costs
Being financially-proof does not mean indulging in wasteful activities. End-stage cancer patients should not receive experimental treatments that do not meet medical necessity. Advanced dementia patients should not be subjected to painful surgery since we are not treating a condition or an organ but the whole patient. What can be done in the office does not need to be done in an ambulatory surgical center (ASC) unless there is a medical reason. What can be done in an ASC does not need to be done in the hospital. Again, medical necessity should be the overriding concern at all times. Evidence-based protocols can also eliminate the fat in the system, e.g., using low-molecular heparin for deep vein thrombosis instead of unnecessary admissions or using intravenous Lasix in CHF clinics for patients with stable cardiac function.
Disease Management Programs and Risk Stratification
These can be remarkably effective in the case of CHF, DM, Hypertension, etc. Risk stratification is essential to identify the sickest patients to take care of them aggressively and see them every day or every week if necessary. It is the highest-risk patients who incur the majority of expenses. They need to have enhanced care and not reduced care – using high-risk clinics, care coordination centers, or team-based care models.
At all levels or points, the focus can only be on quality, outcomes, patient experience, and compliance. In my experience, if these are adhered to, the financial returns will address themselves. Barwick and Nolan have pointed out that quality-based programs in population-based settings reduce utilization while enhancing health care. Referral processes should be timely and well-documented to ensure no delay in care.
Predictive Preventive Care
Appropriate predictive modeling can stratify medical conditions. We can use interviews and surveys combined with analytics and artificial intelligence to control pain, improve bladder function, and enhance activity levels. Using monitors and assistive devices in a home setting will improve communication, assisting those at high risk. Bringing in assigned patients proactively also serves to catch diseases early and bring timely interventions. We can establish executive healthcare clinics where patients can have longer appointments with team involvement and more intense education to improve compliance, providing a more comprehensive review of prior medical conditions.
Eventually, any good UM program is about the whole population and not just individuals. We can utilize group-based interventions, or pre-primary care, to improve our services to the populace. Community resources can impact care meaningfully and facilitate healthcare improvements that may not be possible on an individual scale.
Provider and Staff Education
Constant training of the provider about the tools available to optimize care, along with training in Locally Covered Determinations and Nationally Covered Determinations and ODAG rules, is essential.
Case Managers who are subject matter experts enhance care significantly, empower patients, ensure their rights are honored, and help providers scale care. Care coordination centers with licensed nurses skilled in customer service create another level of communication with patients, along with emails, patient portals, mobile solutions, and discreet use of social media. Discharge dispositions that appropriately assess patients’ needs and abilities can reduce the wasteful use of acute rehab or skilled nursing facilities, or home healthcare.
We can create a Memoranda of Agreement compliant with the Center for Medicare and Medicaid Services to reduce the cost of interventions or devices that are artificially high or to control charge master billing that can be twenty or thirty times Medicare-approved rates. We can evaluate hospital contracts along with ASCs to monitor asymmetric payouts.
Using certifications, like Patient Safety Organizations or PCMHs, creates rigor in processes and induces respect for systems that become independent of subjective or sporadic interventions.
Specialty testing like echocardiograms, pulmonary function tests, Holter monitoring, ultrasounds, and arterial and venous dopplers can be done in-house with competent technicians and read by appropriate specialists.
Use of Specialists
Choosing excellent specialists with lower complication rates and working closely with them can create economies consistently. Using specialists appropriately at the right time and doing interventions at the right time can reduce complications, morbidity, and the costs and medico-legal complications therein. Use good specialists and make good use of specialists. Discussions or disagreements should be objective, based on facts and standards, and not subjective only unless there is a sound basis for one’s judgments.
Patients need to know their rights. They should be able to call the doctor on time and get timely appointments and required treatments. They should be able to have informed discussions and be permitted to bring in their perspectives as partners in their health maintenance. They should also know their responsibilities of presenting facts correctly and not concealing their issues out of fear or embarrassment. Every patient should know they have the right to be heard, treated, helped, and healed. Discussions with patients should be objective, based on standards, and for their complete well-being.
These, in a nutshell, are some of the essential elements of a strong UM program. There may be much more to add but suffice it to say that an effective UM program is not one based on advanced technology but on genuine concern for patients, communication, and advocating for them as one’s friends, partners, and, sometimes, wards.